Adult Health History
Stephen C. Degenhardt, D.D.S., M.S.
Today's Date:
-
Month
-
Day
Year
Date
Date of birth:
-
Month
-
Day
Year
Date
Age:
Sex:
Male
Female
Name:
First Name
Middle Name
Last Name
Nickname:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone (home)
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Phone (cell)
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Phone (work)
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Family Dentist:
City:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Family Physician:
City:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Employed by:
Occupation:
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Orthodontic Insurance:
Yes
No
Marital Status:
Single
Married
Widowed
Divorced
Spouse's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Occupation
Employed by
City
Names and ages of children:
Medical History
General Health:
Good
Fair
Poor
Presently under medical care for:
Birth defects:
Drugs or medication being taken now (drug and dose):
Allergic to (medication, metal, latex, etc.):
Please check yes or no to the following and date:
Adenoids (removed):
Yes
No
Year
Arthritis:
Yes
No
Year
Blood/bleeding problems:
Yes
No
Year
Bone disorder:
Yes
No
Year
Diabetes:
Yes
No
Year
Ear/Nose infections:
Yes
No
Year
Emotional:
Yes
No
Year
Endocrine disorder:
Yes
No
Year
Epilepsy:
Yes
No
Year
Fainting spells:
Yes
No
Year
Glaucoma:
Yes
No
Year
Heart disorder/murmur:
Yes
No
Year
Hepatitis:
Yes
No
Year
Hospitalized:
Yes
No
Year
Lung disorder:
Yes
No
Year
Rheumatic fever:
Yes
No
Year
Scoliosis:
Yes
No
Year
Speech difficulty:
Yes
No
Year
Tonsils (removed):
Yes
No
Year
Sexually transmitted disease:
Yes
No
Year
Do you require antibiotic premedication prior to dental appointments?
Yes
No
If yes, which antibiotics do you usually take?
Please give us any additional information or details where necessary:
Breathing/Airway History (please select all that apply):
Snoring
Teeth Grinding
Bed wetting
Adenoids & tonsil enlargement or removal
Restless sleep at night
ADHD symptoms: hyperactive, difficulty paying attention
Dental History
Date of last dental check-up:
-
Month
-
Day
Year
Date
Injury of trauma to the face or teeth:
Jaw joint (TMJ problems):
Noise
Pain
Earaches/ringing
Soreness & stiffness
Have you noticed or been diagnosed as having any of the following problems due to a poor bite?
Worn or sore teeth
Yes
No
Year
Loose teeth
Yes
No
Year
Bone and gum recession
Yes
No
Year
Headaches and/or jaw joint problems
Yes
No
Year
Speech difficulty
Yes
No
Year
Bruxism and/or clenching
Yes
No
Year
Is there anything you would like to improve about your dental health, smile, or facial appearance? Describe major reason for seeking orthodontic treatment.
Other family members with similar dental conditions and/or orthodontic treatment
Have you had any experience with or seen another orthodontist? If yes, who?
How/when did you first hear about our office?
Whom may we thank for referring you to our office?
Comments/Concerns:
Submit
Should be Empty: